Marian Freedman

A review of current—but limited— studies on the relationship between diet and acne uncovered evidence that some dietary factors may indeed influence acne development and treatment. The implicated factors include glycemic index, dairy content, dietary fats, and probiotics.

Results of several studies demonstrated that patients with acne who consume diets with a low glycemic load (GL) have fewer lesions than those on high-GL diets, as shown in a study of 31 young men with acne that compared a low-GL diet with a control diet. Other findings reveal that eating chocolate and confections daily is independently and highly associated with acne. In addition, results of 2 randomized controlled trials showed that, compared with a carbohydrate-dense control diet, a low-GL diet reduced the number of acne lesions.

A 3-year prospective study of more than 6000 girls found a link between acne and consumption of full-fat, low-fat, and skim milk but no association with non-milk dairy foods, chocolate, and pizza. Yet a similar study of more than 4000 boys found only a weak association between acne and skim milk, and no association with higher-fat milks. Other findings showed that consuming dairy of some sort is positively linked with acne.

Some results suggests that patients with acne may benefit from increased intake of omega-3 fatty acids or γ-linoleic acid. For example, a randomized controlled trial in 45 patients found that supplementation with these fatty acids significantly reduced the number of lesions compared with no supplementation.

Finally, in a small pilot trial in adult patients with acne, probiotics showed promise for reducing acne lesions, but more study is needed to support these early findings. It also appears that diet significantly affects the efficacy of acne treatment, with maximum absorption linked with a fasted state and no consumption of dairy.

This is an interesting review article, but my takeaway is “Who knows what to do?” Milk and chocolate are low-glycemic foods but may still increase acne. Perhaps trial and error in an individual patient is the way to go (and there certainly are good reasons besides acne prevention to limit chocolate and other sweets).

Baldwin H, Tan J. Effects of diet on acne and its response to treatment. Am J Clin Dermatol. 2021;22(1):55-65. doi:10.1007/ s40257-020-00542-y

Articles

For years, teenagers have been told to avoid certain foods to reduce acne. A review article examines the evidence. 

Does diet really play a role in acne?

Children who respond to initial treatment for outpatient community-acquired pneumonia (CAP) are better off following a 5-day strategy than a longer antibiotic course, according to investigators with a randomized placebo-controlled clinical trial. Compared with longer treatment, the shortened approach resulted not only in similar clinical responses and antibiotic-associated adverse effects (AEs) but also in reduced antibiotic exposure and resistance.

The 380 participants, who ranged in age from 6 months to 5 years and came from health care settings in 8 US cities, had nonsevere CAP, and showed early clinical improvement. On day 6 of their originally prescribed therapy, the children were divided into 2 groups and received either 5 more days of their initial antibiotic (standard course group) or 5 days of placebo (short course group). Study drugs were 80 to 100 mg/kg/ day of amoxicillin or amoxicillin/ clavulanate, divided twice daily, or 12 to 16 mg/kg/day of cefdinir, also divided.

The groups did not differ with regard to inadequate clinical response or persistent symptoms (experienced by < 10% of all participants) or antibiotic-associated AEs (generally mild—irritability and diarrhea). The short-course strategy was associated with significantly less likelihood of developing antibiotic-resistance, which investigators detected using DNA from throat swabs at the end of the study.

For years, 10 days of antibiotic treatment was the standard of care for most infections, but we have moved to shorter courses for many entities, such as otitis media in older children, and urinary tract infections. It looks like we can add pneumonia to the list in those rare instances in which an antibiotic is needed in the first place.

Williams DJ, Creech CB, Walter EB, et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: the SCOUT-CAP randomized clinical trial. 

. 2022;176(3):253-261. doi:10.1001/ jamapediatrics.2021.5547

An investigation offers more evidence that shorter antibiotic courses can be just as effective as longer ones.

For community-acquired pneumonia, 5 days of treatment proves superior to 10

Children visiting the emergency department (ED) for management of supraventricular tachycardia (SVT) often undergo diagnostic tests, and the results almost always are normal; even when abnormal, the results are overwhelmingly clinically irrelevant. These were the chief findings of a retrospective study in patients presenting for management of SVT at a single urban tertiary care center during a 7-year period.

The mean age of the 40 patients (who had a total of 92 encounters) was 8.6 years; 50% had a history of SVT and 35% had comorbidities, most often asthma. During the study period, slightly more than half (52.5%) had 1 ED visit, 32.5% had 2 or 3, and 6 had 4 to 17.

More than two-thirds (67%) of patients underwent serologic laboratory evaluation. Eight children had an abnormality, just 1 of which was considered clinically significant enough to warrant intervention. Almost 30% of patients had chest radiography, which revealed no significant findings. Investigators concluded that routine laboratory or radiographic investigation in this population may be unwarranted, given the risk of false-positive results, patient and parent discomfort, and study cost.

Readers of this section should know I am a big proponent of “less is more” when it comes to testing, and here is another reason. When you see a child with SVT, it usually will be sufficient to restore normal rhythm and then refer to cardiology for evaluation.

Taylor RA, Thomas R, Lawrence D. Nonutility of diagnostic testing in ambulatory patients with supraventricular tachycardia. 

. 2022;38(3):e1036-e1040. doi:10.1097/ PEC.0000000000002649

A visit to the emergency department for supraventricular tachycardia (SVT) will often result in a battery of tests. The often normal results for those tests raise the question of whether they're needed.

Diagnostic testing for SVT usually can be skipped

In a case report, surgeons describe performing a right lobectomy using a novel surgical procedure, the transoral endoscopic thyroidectomy vestibular approach (TOETVA), on a 17-year-old adolescent boy with a suspicious thyroid nodule. The patient had a normal postsurgical recovery. His parents and he were satisfied with the cosmetic results: Because TOETVA is performed through a natural opening in the oral cavity, he did not have the scar associated with conventional thyroid surgery.

The procedure called for extending the patient’s neck by placing a pillow under his shoulder in the supine position, putting the chin and sternal notch at the same level for ergonomic study, and making it unnecessary to break the table from the waist, which is done for a standard thyroidectomy. During trocar incisions, the surgeons paid particular attention to avoid damage to mental nerves located on both sides, given that incision locations are crucial to preserve these structures.

The authors noted several advantages of TOETVA over conventional endoscopic techniques for thyroid surgery. First, it not only leaves no visible scars but also offers a shorter dissection distance than conventional surgery. Also, because TOETVA is done with endoscopic equipment similar to that used in laparoscopic cholecystectomy, it provides easy access. Finally, TOETVA is safe and reproducible because it offers significant anatomical landmarks, such as the location of trocar incisions, cricoid cartilage, trachea, strap muscles, sternocleidomastoid muscles, and sternal notch.

Here is another fascinating concept: First came laparoscopic operations, and now this. Surgeons can be very creative, but this is still far from general use. Avoiding visible scars is nice, but we will need to see if this approach results in less morbidity and faster recovery, the true major benefits of laparoscopic surgery.

Divarci E, Ulman H, Ozok G, Ozen S, Ozdemir M, Makay O. Transoral endoscopic thyroidectomy vestibular approach (TOETVA): a novel surgical technique for scarless thyroidectomy in pediatric surgery. 

. Published online February 1, 2022. doi:10.1016/j.jpedsurg.2022.01.038

A case report shares a new surgical approach that holds promise for scarless thyroidectomy procedures.

A novel surgical approach offers scarless thyroidectomy

In extremely low gestational age newborns (ELGANs), certain demographic factors and less-than-optimal respiratory support in or beyond the neonatal intensive care unit (NICU) can increase the risk of abnormal lung function at 1 year of age. Those are the major findings of a study in 135 ELGANS born at 6 hospitals across the United States.

Following the newborns’ discharge from the NICU, investigators collected quarterly data about the infants’ respiratory symptoms; emergency department (ED) or hospital admissions for respiratory indications; cardiopulmonary medications; and use of supplemental oxygen or ventilatory support. Investigators also collected perinatal demographic data and performed infant pulmonary function tests (iPFTs) when the babies were 1 year of age.

 scores for all iPFT values were significantly lower except lung function and respiratory system resistance, with the latter significantly higher. Of 6 adverse events, just 1 was deemed serious, and the infant recovered immediately after testing.

With regard to correlations between NICU and post-NICU clinical factors and iPFTs, for each week’s decrease in gestational age, forced expiratory flow (FEF) at 75% of forced vital capacity (FVC) decreased 9.5%. Other neonatal factors associated with significantly lower or abnormal iPFTs included intubation at delivery, need for invasive ventilation at more than 30 weeks’ postmenstrual age (PMA) or noninvasive ventilation at more than 36 weeks’ PMA, treatment with diuretics or systemic steroids, and weight below or equal to the 10th percentile at 36 weeks’ PMA.

Prenatal and family factors generally had no effect on iPFTs, but ED or hospital admissions for respiratory indications, cardiopulmonary medication, and use of supplemental oxygen or ventilatory support were significantly associated with lower iPFTs. Among demographic factors, being male and Black increased the likelihood of a significant decrease in forced expiratory volume 0.5 or FEF at 75% of FVC. Just 7% of the infants had reversible airflow obstruction.

I sometimes squeeze infant’s chests (gently) to elicit a wheeze, but it appears it can now be done in a standardized fashion. Prior to this, iPFTs were a pipe dream, but technology marches on. I also note that bronchodilators usually do not help these children, just as they are not of benefit with viral wheezing.

Voynow JA, Feng R, Ren CL, et al. Pulmonary function tests in extremely low gestational age infants at one year of age. Pediatr Pulmonol. 2022;57(2):435-447. doi:10.1002/ppul.25757

An investigation examines what demographic factors and less-than-optimal respiratory support in or beyond the neonatal intensive care unit can increase the risk of abnormal lunch function on extremely low gestational age newborns (ELGANs).

Which ELGANs are most at risk of low lung function?

Infants given phototherapy as first-line treatment for neonatal jaundice are more likely to develop neoplasms, both benign and malignant, according to findings of a large retrospective study. The investigation included all infants born at 32 or more weeks’ gestation at a single medical center in Israel during a 30-year period. In the study population of more than 342,172 infants, 5.5% were exposed to phototherapy and followed up at a median of 9.5 years. Mothers of exposed children were more likely to be of Jewish than of Arab-Bedouin ethnicity and to have had pregestational or gestational diabetes mellitus. Exposed children also were more likely to have been delivered at an earlier gestational age or via cesarean delivery and to be male.

Malignant neoplasms were diagnosed in 531 children (0.15%); benign tumors, in 1921 (0.72%). Malignant tumors were more likely to develop in the exposed children. The association with malignant neoplasms remained among both children born at term and those born prematurely, even after adjusting for preterm birth and maternal age. Specifically, phototherapy was associated with hematopoietic cancers and leukemia but not solid tumors and lymphoma.

Parents may ask about this, so be prepared. The authors do cite another large study with different conclusions. For me, the bottom line is that the risk of kernicterus outweighs the risk of neoplasm, provided phototherapy is used judiciously. Most infants seen in the office with elevated bilirubin will not have levels warranting more than serial follow-up.

Bugaiski-Shaked A, Shany E, Mesner O, Sergienko R, Winstock T. The association between neonatal phototherapy exposure and childhood neoplasm. J Pediatr. Published online February 1, 2022. doi:10.1016/jpeds.2022.01.046

Phototherapy is a typical first-line therapy for jaundice. A recent study examines whether the use alters neoplasm risk.